sacrospinous colpopexy using masson luethy needle holder

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European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx

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Sacrospinous colpopexy using Masson luethy needle holder

Ahmed Ibrahim 1, Osama Eltohamy 1, Moustafa Ibrahim 1, Mohamed I. Ellaithy 1,*,Ahmed Bahaa 1, Mohamed Elkady 1, Ihab Samaha 1

Obstetrics and Gynecology Department, Faculty of Medicine, Ain-shams University Maternity Hospital, Cairo, Egypt

A R T I C L E I N F O

Article history:Received 23 December 2013Received in revised form 12 April 2014Accepted 24 April 2014

Keywords:Masson luethy needle holderPelvic organ prolapseSacrospinous colpopexy

A B S T R A C T

Objective: Sacrospinous colpopexy (SSC) is a well-known surgical technique to correct apical supportdefect, however its approach is still challenging. The current study describes an alternative and economicapproach for suture placement in the sacrospinous ligament during SSC using Masson luethy needleholder.Study design: A prospective study was conducted in a tertiary care center. The study recruited womenwith uterovaginal prolapse or post hysterectomy vaginal vault prolapse scheduled for SSC as aconstructive surgery for vaginal superior segment defect. Eligible women were assigned to have SSCusing Masson luethy needle holder (Group I) for suture placement in the sacrospinous ligament. Thecontrol group (Group II) consisted of a group of patients who had SSC using Deschamps ligature carrier.Results: By the end of the study, 104 women underwent SSC. (Group I) included 55 women while (GroupII) included 49 women. The mean SSC operative time was significantly shorter in (Group I) [109 � 33 minversus 206 � 67 min in (Group II), p < 0001], with a mean difference of 10.5 min [95% CI, 74–136]. Thisdifference in SSC operative time was due to faster suture placement in (Group I) [47 � 14 min versus153 � 46 min in (Group II), p < 0001]. The mean SSC related operative blood loss was significantly less in(Group I) [582 � 349 ml versus 985 � 463 ml in (Group II), p < 0001]. The perioperative complications,recurrence and cure rates were similar in both groups.Conclusion: Using Masson luethy needle holder reduced the difficulty associated with suture placementduring SSC and allowed the completion of the procedure within a significantly shorter time.

ã 2014 Published by Elsevier Ireland Ltd.

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology andReproductive Biology

journal homepage: www.elsevier .com/ locate /e jogrb

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Introduction

Surgical management of pelvic organ prolapse can beperformed via laparoscopic, abdominal or vaginal approaches.Although the abdominal approach was reported to have the lowestrecurrence rate [1], the vaginal approach is superior as it is lessinvasive and allows concomitant repair of other support defects inother vaginal compartments in the same setting [2].

Sacrospinous colpopexy (SSC) is a well-known vaginal approachfor correction of apical support defect that has a comparableoutcome to the more invasive abdominal approach [3,4], however;till now, it is underused because of its technical difficulty [3,5]. Inorder to render this operation less challenging, many instrumentshave been described to facilitate suture anchoring to the

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* Corresponding author at: Base villa 16, King Faisal military city, KhamisMushait, Saudi Arabia. Tel.: +96 6541022177.

E-mail address: [email protected] (M.I. Ellaithy).1 All authors have contributed significantly and are responsible about the content

of this manuscript.

http://dx.doi.org/10.1016/j.ejogrb.2014.04.0350301-2115/ã 2014 Published by Elsevier Ireland Ltd.

Please cite this article in press as: Ibrahim A, et al. Sacrospinous colpopehttp://dx.doi.org/10.1016/j.ejogrb.2014.04.035

sacrospinous ligament during SSC [6]. Deschamps ligature carrierwas the first to be used to insert silk ligatures through thesacrospinous ligament [7], in the last 20 years, many instrumentshave also been described for the same purpose [6,8–13] andrecently, CapioTM suture capturing device was described toovercome the fore mentioned difficulty [14].

Herein, we described an alternative way for suture placement inthe sacrospinous ligament during SSC using Masson luethy needleholder and compared it with the traditional Deschamps ligaturecarrier.

Materials and methods

This prospective study was conducted in Ain Shams universitymaternity hospital in the period from July 2008 to December 2012after being approved by the local institutional ethics and researchcommittee. The study recruited women with uterovaginal prolapseor post hysterectomy vaginal vault prolapse who were scheduledfor SSC as a constructive surgery for vaginal superior segmentdefect. All recruited women were thoroughly evaluated for pelvicsupport defects and urinary incontinence. Only women with stage

xy using Masson luethy needle holder. Eur J Obstet Gynecol (2014),

mailto:

http://dx.doi.org/10.1016/j.ejogrb.2014.04.035



http://www.sciencedirect.com/science/journal/03012115

www.elsevier.com/locate/ejogrb

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Fig. 1. Masson luethy needle holder [Courtesy of Aesculap AG, Am Aesculap Platz,78532 Tuttlingen, Germany, item code: BM280R].

2 A. Ibrahim et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 2 xxx (2014) xxx–xxx

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o or more apical prolapse were included in the study (according pelvic organ prolapse quantitation, POP-Q system) [15]. Thoseith severely shortened vagina or recurrent vaginal vault prolapseere excluded. Eligible women who accepted to participate in theudy were assigned to have a unilateral (right sided) SSC usingther Masson luethy needle holder (Group I) for suture placement

the sacrospinous ligament. The control group (Group II)nsisted of a group of patients who had SSC using Deschampsature carrier. All participants signed a written informed consentrm. Women with uterovaginal prolapse had vaginal hysterecto-y followed by site specific reconstructive surgery and SSC.SSC was done via performing a longitudinal incision in thesterior vaginal wall 1–2 cm below the level of the closed vaginalult till the introitus inferiorly. Dissection of the vagina from thectum was then done followed by the pararectal fascia. Arforation in the rectal pillar was done bluntly or by the use ofong hemostat and widened in a plane parallel to the rectum. Thecrospinous ligament was inspected by using three Briskyvratil retractors, one anteriorly at 12 o‘clock position to protecte peritoneal sac, a second retractor at 4 o‘clock position tootect the rectum medially and a third one at 7 o‘clock position totract the convex bulge of the levator ani muscle to help insualization of the ligament. Two sutures were passed through theament, the first was polyglactin suture (no.1, with needle 40 mm,2 circle) 2–3 cm medial to the ischial spine and a secondlypropylene suture (no.1, with needle 40 mm, 1/2 circle) passededial to the first. The two sutures were then passed through thell thickness and the under surface (avoiding the vaginalithelium) of the posterior wall of vaginal vault respectivelyd held by hemostats. The posterior colpoperineorrhaphy wasen done. The posterior vaginal wall was closed from abovewnward with continuous stitches leaving 2–3 cm inferiorly, anden the colpopexy sutures were tied to fix the vault to theament. Finally the closure of posterior vaginal wall wasmpleted and a vaginal pack was left for 24 h.Suture placement in (Group I) was performed using Masson

ethy needle holder (Aesculap AG, Am Aesculap Platz, 78532ttlingen, Germany, item code: BM280R) (Fig. 1) which is anestrated needle holder of about 26 cm in its length with awnward curve in its shaft which improve the visibility of theedle tip and the ligament. There are two characteristicnestrations in its upper and lower jaws which allow passage

a needle through them. The lower jaw has three serrations orooves; one of them is longitudinal towards its tip while the othero are oblique. The 40 mm Mayo needle carrying the desiredture was passed through the fenestration in the upper jaw to becommodated in the longitudinal groove in the lower jaw in suchway that, if the holder is locked the needle will be fixed in itssition, in line with the needle holder. After adjusting the exposedorking length of the needle, the handle of the holder was movedwards the symphysis pubis to allow the needle tip to hit thewer border of the ligament then the needle holder was pushed toss the needle through the ligament helped by downwardovement of the handle until the needle tip emerged out justlow the upper border of the ligament. The needle was thentrieved by using a long curved forceps. The bite taken throughe ligament can be controlled by the length of needle pushedside the ligament before it emerges out. All the procedures werenducted by the same team of surgeons who are qualified andperienced in performing SSC.The primary outcome measure was the suture placement timeeasurement of suture placement time was a reasonable way tompare the degree of difficulty in suture placement between the 2oups). The time for suture placement in SSC was calculated frome beginning of first suture placement under direct vision afterposure of the ligament till finishing the second suture placement.

Please cite this article in press as: Ibrahim A, et al. Sacrospinous colpophttp://dx.doi.org/10.1016/j.ejogrb.2014.04.035

Other outcomes included operative blood loss, complicationsrelated to SCC procedure and SSC operative time, this time wasdefined as time needed for penetration of pararectal fascia, sutureplacement and tying of ligatures. Postoperatively, all participantswere followed up after 1, 3, and 6 months then yearly. Two types ofcure rates were measured (objective and subjective), objective curewas defined as re-establishment of normal anatomy or stage 1prolapse according to POP-Q system, while subjective cure wasdetermined according to the patient satisfaction from disappearanceofsymptoms ofprolapse. Recurrenceofvault prolapsewasdefined asthe presence of �stage 2 prolapse according to POP-Q system.

Study sample size was calculated based on data from a previouspilot study performed on 5 women planned for SSC using theDeschamps ligature carrier. The mean suture placement time inthose women was 16.4 � 3.8 min. It was assumed that at least 50%reduction in suture placement time would be clinically valuable.The calculation according to these values, setting the power at 80%and the type-1 error (alpha) at 0.05, showed that any sample sizewould be justified to show a significant difference if there shouldbe. The least statistically acceptable sample size was 25 cases ineach group.

Statistical analysis was performed using IBM SPSS Statistics forWindows version 20 (IBM Corp, Armonk, NY). Normality ofquantitative (numerical) data distribution was tested using theShapiro–Wilk goodness of fit test. Variables were presented as meanand standard deviation (for numeric parametric data), median andinterquartile range (for numeric non-parametric data), and numberand proportion (for categorical data). Variables were comparedbetween the 2 groups using Student t-test (for numeric parametricdata), Mann–Whitney’s U-test (for numeric non-parametric data),and Fischer’s exact and chi-squared tests (for categorical data).Probability level (p value) was assumed significant if less than 0.05.

exy using Masson luethy needle holder. Eur J Obstet Gynecol (2014),


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Table 2Operative Q7data.

Demographics Group I(n = 55)

Group II(n = 49)

p

Operative time (min)a, mean � SD 10.9 � 3.3 20.6 � 6.7 <0.001*

Operative time (min)b, mean � SD 4.7 � 1.4 15.3 � 4.6 <0.001*

Operative blood loss (ml)c, mean � SD 58.2 � 34.9 98.5 � 46.3 <0.001*

Concomitant surgical procedures, n (%)VH 49 (89.1%) 44 (89.8%) 0.907**

Anterior repair 51 (92.7%) 44 (89.8%) 0.856**

Paravaginal repair 2 (3.6%) 0 (0%) 0.856**

Kelly’s sutures 4 (7.3%) 2 (4.0%) 0.783**

TOT 6 (10.1%) 3 (6.1%) 0.605**

Culdoplasty 5 (11.1%) 4 (8.3%) 0.867**

Posterior repair 55 (100%) 49 (100%) 1.000**

Complicationsc, n (%)Bleeding/blood transfusion 0 (0%) 0 (0%) 1.000**

Rectal injury 0 (0%) 1 (2.0%) 0.954**

Data are presented as mean � SD or n (%) as appropriate.n, number; SD, standard deviation; VH, vaginal hysterectomy.

a Space preparation, ligament visualization and placement of sutures.b Suture placement time.c Related to sacrospinous colpopexy.* Analysis using independent student’s t-test.** Analysis using chi-squared test.

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Results

By the end of the current study, 104 women underwent SSC andwere included in the study statistical analysis. The mean age ofincluded women was 51.9 � 6.7 years, of these women, 73(70.2%)women were postmenopausal. The median parity was 4(IQR, 2–7).The mean body mass index (BMI) was 30.5 � 3.7 kg/m2. Of theincluded 104 women,11(10.6%) underwent previous hysterectomy,11(10.6%) previous posterior repair, 10(9.6%) previous classicalrepair, 6(5.8%) previous Burch colposuspension, 10(9.6%) previoustransobturator tape (TOT). (Group I) included 55 women while(Group II) included 49 women. There were no statisticallysignificant differences between both groups regarding age,menopausal status, parity, BMI, hemoglobin concentration,prolapse stage, or presence of previous relevant surgery (Table 1).

Intraoperatively, the mean blood loss related to SCC was78.4 � 40.6 ml, the mean suture placement time was 10.0 � 6.0 minand only one woman had rectal injury. Of the included women, 93(89.4%) underwent concomitant vaginal hysterectomy (VH), 95(91.3%) concomitant anterior repair, 2(1.9%) concomitant para-vaginal repairs, 6(5.8%) concomitant Kelly’s sutures, 9(8.7%)concomitant TOT and 9(8.7%) concomitant culdoplasty. All of theincluded women underwent concomitant posterior repair. Therewere no statistically significant differences between women ofboth groups regarding concomitant surgical procedures or SSCrelated operative complications (Table 2).

The mean SSC operative time, including the time required forperirectal space preparation, visualization of sacrospinousligament and placement of sutures, was significantly shorter in(Group I) [109 � 33 min versus 206 � 67 min in (Group II),p < 0001], this difference in SSC operative time was due to fastersuture placement in (Group I) [47 � 14 min versus 153 � 46 min in(Group II), p < 0001]. Using the Masson luethy needle holder ratherthan the Deschamps ligature carrier was associated with asignificantly shorter SSC operative time with a mean differenceof 10.5 min [95% CI, 74–136]. Group I had significantly lower SSC

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Table 1Demographic and Q6preoperative data.

Demographics Group I(n = 55)

Group II(n = 49)

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Age (years), mean � SD 51.6 � 6.9 52.2 � 6.6 0.640*

Menopausal status, n (%) 0.366**

Premenopausal 19 (34.5%) 12 (24.5%)Postmenopausal 36 (65.5%) 37 (75.5%)Parity, median (IQR) 4 (3–5) 4 (3–5) 0.831***

BMI (kg/m2), mean � SD 30. 1 � 4.0 30.9 � 3.4 0.290*

Hemoglobin (gm/dl), mean � SD 12.4 � 1.2 12.1 � 1.2 0.327*

Preoperative POP-Q stage, n (%)Stage I 0 (0%) 0 (0%) 1.000**

Stage II 16 (29.1%) 13 (26.5%) 0.829**

Stage III 31 (56.4%) 29 (59.2%) 0.844**

Stage IV 8 (14.5%) 7 (14.3%) 1.000**

Prior hysterectomy, n (%) 6 (10.9%) 5 (10.2%)Abdominal 3 (5.5%) 2 (4.1%) 0.744**

Vaginal 2 (3.6%) 2 (4.1%) 0.906**

Laparoscopically assisted vaginal 1 (1.8%) 1 (2.0%) 0.934**

Prior prolapse surgery, n (%) 11 (20.0%) 10 (20.4%)Classical repair 6 (10.9%) 4 (8.2%) 0.888**

Posterior repair 5 (9.1%) 6 (12.2%) 0.839**

Prior continence surgery, n (%) 9 (16.4%) 7 (14.3%)Burch 4 (7.3%) 2 (4.1%) 0.783**

TOT 5 (9.1%) 5 (10.2%) 0.848**

Data are presented as mean � SD, n (%) or median (IQR) as appropriate.BMI, body mass index; IQR, interquartile range; n, number; POP-Q, pelvic organprolapse quantification; SD, standard deviation; TOT, transobturator tape.

* Analysis using independent student’s t-test.** Analysis using chi-squared test.*** Analysis using Mann–Whitney’s U-test.


related operative blood loss [582 � 349 ml versus 985 � 463 ml in(Group II), p < 0001].

Postoperatively, the mean follow up time was 25.7 � 6.9 monthsand the mean postoperative hemoglobin was 11.15 � 2.1 gm/dl.11 women experienced postoperative complications, (gluteal pain in7 women, fever in 6 women and hematoma in 1 woman), thatresolved spontaneously by conservative treatment. 8 women hadrecurrent vault prolapse, of whom only 3 required repeated surgicalintervention. The subjective cure rate was 95.2% while the objectivecure rate was 92.3%. Apart from the hemoglobin level, there were nostatistically significant differences between women in both groupsregarding the postoperative and follow up data (Table 3).

Table 3Postoperative and follow up data.

Group I(n = 55)

Group II(n = 49)

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Hemoglobin (gm/dl), mean � SD 11.6 � 2.0 10.7 � 2.2 0.0305*

Postoperative complications, n (%) 6 (10.9%) 5 (10.2%)Gluteal pain 4 (7.3%) 3 (6.1%) 1.000*

Fever 3 (5.5%) 3 (6.1%) 1.000**

Hematoma 0 (0%) 1 (2.0%) 0.954**

Follow up (month), mean � SD 24.6 � 5.4 26.8 � 8.4 0.112*

Postoperative POP-Q stage, n (%)No prolapse 44 (80.0%) 39 (79.6%) 0.959**

Stage I 7 (12.7%) 6 (12.3%) 0.941**

Stage II 4 (7.3%) 3 (6.1%) 0.815**

Stage III 0 (0.0%) 1 (2.0%) 0.954**

Stage IV 0 (0.0%) 0 (0.0%) 1.000**

Subjective cure, n (%) 53 (96.4%) 46 (93.9%) 0.895**

Objective cure, n (%) 51 (92.7%) 45 (91.8%) 0.865**

Recurrencea, n (%) 4 (7.3%) 4 (8.2%)Apical 1 (1.8%) 1 (2.0%)Anterior wall 2 (3.6%) 1 (2.0%)Posterior wall 0 (0.0%) 0 (0.0%)Combined 1 (1.8%) 2 (4.1%)Recurrence (requiring re-operation) 1 (1.8%) 2 (4.1%) 0.919**

Data are presented as mean � SD or n (%) as appropriate.n, number; POP-Q, pelvicorgan prolapse quantification; SD, standard deviation; VH,vaginal hysterectomy.

a Prolapse equivalent to stage 2 or more according to POP-Q system.* Analysis using independent student’s t-test.** Analysis using chi-squared test.



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Table 4Instruments used to Q8facilitate SSC in the previous studies.

Instruments Studies

Authors Subjects and design Follow up(months)

Operativetime (min)

Blood loss(ml)

ComplicationsRecurrence

Deschamps ligature carrier[7,16,23]

Randal(1971) [23]

18 patients22 controls = abdominal sacropexy

NR NR NR Complications(none)Vault prolapse(none)

Miya hook[11,24]

Cruikshank[24]

48 patientsNo controls

24 18.5b 100 Cystocele (n = 5)Rectocele (n = 2)Vault prolapse(n = 1)

Shutt Suture Punch System (arthroscopic ligature carrier)[12,25]

Marcickiewiczet al. (2013) [25]

20 patients53 controls = 31 SSC with Deschamps and 22SSC with a straight needle holder

40.3(7–108)

58.5b

(30–123)(p > 0.05)

49.78(0–250)(p > 0.05)

Reoperation (n = 1)Transfusion (n = 1)Satisfied women(n = 16)

Endo Stitch[13,17]

Watson(1996) [13]


7 NR NR Complications(none)

Schlesinger(1997) [17]


9.8 � 4.2 18.5 � 3.0b �100(88.2%)<200(11.8%)

Complications(none)Recurrence (n = 2)

Laurus needle driver (in-linesuturing device)[10]

Lind et al.(1997) [10]


4–6 <2a 100–200 Complications(none)Recurrence (none)Gluteal pain (n = 1)

Raz Anchoring System (RAS)[9]

Giberti(2001) [9]


16(12–23)

8–15b NR Complications(none)Vault prolapse(n = 1)

Veronikis ligature carrier (VLC)[6,26,27]

Veronikis et al.(1997) [6]


1.5 (n = 71)6 (n = 58)

3a NR Complications(none)Recurrence (none)

Chou et al.(2010) [27]


36(12–60)

34(20–55)b

<5a79(50–400),SSC

Gluteal pain (n = 1)Recurrent vaultprolapse (n = 4)Recurrent stage 1cystocele (n = 3)

Capio device[14]

Maggiore et al.(2013) [14]

44 patients42 retrospective controls = traditional SSC

36 21.4 � 3.2b

(p < 0.001)98 � 40(p < 0.001)

UTI (n = 3).Objectivecure = 86.4%Subjectivecure = 100%

Aksakal automatic suturinginstrument[8,28]

Aksakal et al.(2007) [8]

27 patients30 controls = SSC with Deschamps

6 <1a

(�48 s)(p < 0.001)

NR Complications(none)

Doganay et al.(2013) [28]


NR <1a (�46 s)(p < 0.001)

260(90–660)(p < 0.05)

Gluteal pain (n = 4)Hematoma (n = 2)

Masson luethy needle holder Current study(2014)


24.6 � 5.4 4.7 � 1.4a

(p < 0.001)58 � 34(p < 0.001)

Complications(n = 6)Objective cure(n = 51)Subjective cure(n = 53)Recurrence (n = 8)

min, minutes; n, number; NR, not recorded; RAS, Raz Anchoring System; s, seconds; SSC, sacrospinous colpopexy; SSL, sacrospinous ligament; UTI, urinary tract infection;VLC, Veronikis ligature carrier.

a Indicates SSC suture placement time.b Indicates SSC total operative time.


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mment

SSC is a well-known technically challenging vaginal operationed for surgical repair of apical prolapse that was first described

Sederl [7] then spread in 1980s by Nichols in the United States6] and Richter and Albrich in Europe [3].Over years, several instruments have been described to

cilitate suture placement and retrieval and consequently reducee reluctance or the hesitancy to consider SSC for surgical repair ofical prolapse (Table 4).Wide dissection and use of retractors are necessary for suture

acement and retrieval under direct vision in SSC using


Deschamps ligature carrier [7], Miya hook [11] and Veronikisligature carrier [6]. In spite of using direct visual approach, stillsuture retrieval is sometimes very difficult and may be frustratingand may leads to fraying of the sutures.

The Shutt Suture Punch System [12] and the AutosutureEndostich device [17] provide automatic suture retrieval and alower operative time however, the bite taken from the ligamentmay be less than adequate [10] in addition to the high cost perevery patient being disposable instruments.

The limitation to a very thin suture material which may be notsuitable for SSC in addition to the high cost constitute thedisadvantage of the disposable Laurus device [10].



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The concept of using the conventional needle holder in SSC ifthe surgeon has enough experience to work in the narrow and deeppararectal space comfortably has been approved by some authors[18].

The penetrating part in Deschamps ligature carrier and theneedle in conventional needle holder are present perpendicular tothe shaft of Deschamps ligature carrier and the needle holder andthis limits the visualization of the ligament by the surgeon’s handitself during suture placements with the resultant difficultplacement and retrieval. In addition the surgeon sometimesstands up and takes the position of the assistant so that he canplace the sutures.

In this study we adopt this straight and fenestrated needleholder to overcome the difficulty encountered in SSC especially theinsertion and retrieval of sutures which was reflected on the muchreduction of suture placement time. The conventional Mayo needlecan be used in line with the needle holder in addition to downwardcurve in the shaft of the instrument to simplify the procedure.

The Masson luethy needle holder is like any conventionalneedle holder can be sterilized and reused for unlimited times. Thepresence of longitudinal grooves in the lower jaw and the passageof the needle through the fenestration in the upper jaw make theneedle fixed in its position and not liable to be lost. There was noneed for any change in the operating theatre or the position of thepatients while using the new instrument.

The retrieval of a needle is much easier than retrieval of a suturematerial and also avoids partial suture destruction or fraying.Different types of suture material and different sizes of needles canbe used according to the situation. The bulk of tissue taken fromthe ligament can be controlled by the surgeon by pushing theneedle through the ligament to the desired depth.

Richter described SSC procedure via direct visualization ofsacrospinous ligament [3], the technique is rather difficult and itsexposure is sometimes insufficient. Nichols [16] proposed a blindpalpatory approach, however vascular damage during ligamenttransfixion is likely. Salvat et al. [19] adopted a techniquecombining palpation and visualization to avoid the risk ofbleeding. In the present study, the use of needle holder requiredthe use of direct visualization approach with all its potential meritsand demerits was utilized. Although this approach necessitateswide dissection for proper placement of retractors and sutureretrieval with possible vascular and nerve damage, it is known tobe safe and easy to use, provides direct visualization ofsacrospinous ligament region and utilizes the safe perirectalspace. The use of this approach did not increase the rate of SSCrelated perioperative complications when compared with thatpublished in the literature. In a meta-analysis of 149 studiesincluded 2390 patients, the reported complications of SSC were:bleeding (1.9%), hematoma (0.4%), nerve injury (1.8%), gluteal pain(2%), cystitis (4.5%), bladder perforation (0.8%), ureteric and otherurologic complications (2.9%) and thrombophlebitis (0.5%) [20].

The estimated recurrence rate of vaginal vault prolapse is 18%and occurs mainly in relation to the anterior vaginal wall [21]. Thepresent study, recurrence was defined as the presence of stage 2 ormore prolapse according to POP-Q system [15], 8 women hadrecurrence but 3 only required repeated surgical intervention.

Unilateral rather than bilateral SSC is preferred by mostsurgeons, and they usually perform it on right side as colon entersthe rectum on the left side [20]. In the present study, right sidedSSC was the procedure of choice used in all participants.

In women with recurrent vault prolapse, pararectal spacescarring and distorted anatomical landmarks make secondary SSCdifficult and increase the risk of rectal injury. Left sided SSC andabdominal approach were suggested by other authors as goodalternatives [22]. In the current study, women with recurrent vaultprolapse were excluded.


One of the potential points of criticism to the present study isthat randomization was not used for patients’ allocation, howeverboth groups were appropriately and adequately matched whichreduced the potential bias. The current study has the potentialadvantages of novelty, prospective recruitment of large number ofpatients, and the use of control group.

In conclusion, using Masson luethy needle holder in SSCresulted in much reduction in the level of difficulty of thisprocedure and many surgeons in our hospital started to use theprocedure after being hesitant for many years to do it at the time ofsurgical repair of apical prolapse. We can assume that this reusableinstrument can be a very good alternative to other instruments inSSC especially in developing countries with limited resourcesowing to its minimum cost per the individual patient.

Acknowledgement

Special thanks to Dr. Helmy Metawe and Dr. MohamedAbdelhameed, Professors of Obstetrics and Gynecology, Ain-shamsUniversity as they performed the data analysis, and criticallyrevised the manuscript for the intellectual and scientific contents.

Appendix A. Supplementary data

Supplementary data associated with this article can be found, inthe online version, at http://dx.doi.org/10.1016/j.ejogrb.2014.04.035.

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